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Press Release

For Immediate Release
For Information Contact:
Patricia Montone Charvat

Stopping the Spread of MRSA:
MD Hospitals Engaged in Innovative Approach that is Making a Difference

Baltimore, Maryland, October 15, 2007 - A diverse group of healthcare providers representing hospitals, nursing homes, and dialysis facilities from Maryland, the District of Columbia and Northern Virginia are joining together with the Maryland Patient Safety Center to counteract the escalating problem of healthcare-associated infections, including Methicillin-Resistant Staphylococcus Aureus (MRSA), a virulent strain of bacteria commonly found on the skin.

Last week leaders from more than 45 hospitals, rehabilitation centers, and dialysis centers gathered in Maryland and Washington, D.C. to expand an innovative pilot program that has been yielding striking results in reducing the transmission of MRSA.

"Preventing and controlling infections caused by MRSA and other drug-resistant organisms is a national priority," said Bill Minogue, MD, Executive Director of the Maryland Patient Safety Center. "An effective response requires that all health care facilities and agencies become engaged in finding solutions. The Patient Safety Center is committed to playing a leading role in fostering these collaborative efforts."

"One of the biggest myths about healthcare-associated infections is that they are the result of just a few people's actions" says Margaret M. Toth, MD, a member of the Patient Safety Center's Leadership team and the Chief Quality Officer for the Delmarva Foundation. "In fact, everyone who works in, is cared for by, or simply visits someone in a health care facility can be inadvertently spreading MRSA."

"These infections have emerged over decades in crowded settings, especially those where we care for the sick and vulnerable. The risk of spreading infection from one person to the next by way of our hands, clothes, and equipment is very real. Every person who interacts with patients in those settings needs to take part in the actions that will lower the risk of infection."

There are effective ways of reducing transmission: hand washing or use of an alcohol-based sanitizer before and after every patient contact and before and after putting on gloves; wearing gowns when visiting or caring for people who are sick or carry bacteria like MRSA; identifying affected patients; and meticulous cleaning of the environment and equipment. "However," explains Dr. Toth, "as lives and institutions become more complex and hectic, even doing these seemingly simple things consistently can become overwhelming."

That is why ten hospitals in Maryland are now using a dramatically different approach than the usual educational campaigns targeted at health care workers. This new approach recognizes our shared responsibility in identifying possible avenues for infection transmission, and our potential for making rapid and lasting improvements.

Using Positive Deviance, a method for encouraging behavior change with a quirky name and long history of success in the developing world, these hospitals started looking for the unique but different practices that already existed within their units that made it possible for everyone to always follow infection prevention practices:

  • Within months hooks were placed outside the patient rooms in one hospital so doctors had a place to hang their white coats while wearing protective gowns in isolation.

  • Clergy in another institution started covering their bibles with surgical caps - so they didn't carry infections from patient to patient.

  • Housekeeping staff developed checklists for cleaning rooms and then tested the effectiveness of their new and improved process with a glow-in-the-dark chemical that showed the spots they missed.

  • One nurse mentioned that she stocked her ICU patients rooms with full bottles of hand sanitizer each morning - so health care workers, therapists, family and other visitors could easily remember to always wash their hands. Now all the nurses on her unit are doing the same thing.

Two Maryland hospitals were among the six selected nationally in 2005 by the Plexus Institute to launch the first use of Positive Deviance in U.S. hospitals through a Robert Wood Johnson Foundation funded program. In 2006 the Maryland Patient Safety Center worked with seven additional hospitals in a CareFirst BlueCross BlueShield-funded expansion of the Positive Deviance initiative. Several VA hospitals, including some facilities in this region are also testing this approach.


About the Maryland Patient Safety Center
The Maryland Patient Safety Center brings together hospitals and health care providers to improve patient safety and health care quality for all Marylanders. The goal of the Patient Safety Center is to make Maryland's health care the safest in the country by focusing on the systems of care, reducing the occurrence of adverse events, and improving the culture of patient safety at Maryland health care facilities.

The Maryland Patient Safety Center is jointly operated by the Maryland Hospital Association and the Delmarva Foundation. It received the 2005 John M. Eisenberg Patient Safety and Quality Award as a national/regional innovation in patient safety. The Patient Safety Center has conducted patient safety training and break through collaboratives for more than 6,000 Maryland health care workers. The Patient Safety Center is viewed as a unique national model of success because of its comprehensive approach to patient safety which includes:

  • education and training;
  • safety culture collaboratives which, to date have focused on intensive care units and emergency departments. One collaborative under way focuses on creating perinatal units that deliver care safely and reliably with zero preventable adverse outcomes and reducing infant harm through the implementation of systems improvements and team behaviors using proven methods;
  • eliminating Methicillin-Resistant Staphylococcus aureus (MRSA) infections by tapping the wisdom of people on the front lines to solve this seemingly intractable problem;
  • promoting the safe use of medications (MEDSAFE);
  • adverse event information system and data analysis; and
  • research on topics identified through its initiatives.

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